Vaccum-Assisted Thrombectomy in AVF and AVG
This prospective study included 35 patients with acutely thrombosed AVF and AVG that underwent Thrombectomy using the Indigo device. The study sought out to evaluate if the Indigo system would be safe, effective, decrease procedure time and complications. No patient was excluded during the study period. The authors used systemic heparin (no TPA), obtained antegrade and retrograde access to treat the thrombus, with adjunctive use of angioplasty and or stents for stenosis, occlusion balloon for thrombus in the arterial anastomosis and Trerotola device for adherent thrombus in an aneurysmal segment. The authors evaluated technical and clinical success, primary patency, primary assisted patency, and secondary patency, procedure time, blood loss and complications. Technical success was 34 out of 35 patients, with clinical success in 32 out of 35 patients. Three complications were not attributed to the device. As expected 93% of patients required angioplasty, 2 patients stent grafts, 1 patient required Trerotola device and 2 patients occlusion balloon. Average procedure time was 38 minutes, average blood loss was 122 mL, 6 month primary patency, primary assisted patency and secondary patency was 71%, 80% and 88.5%. The results of this study demonstrate high technical and clinical success, comparable or better to other studies published. Average procedure time (38 minutes) was also improved when compared to Angiojet (78 minutes), mechanical thrombolysis (126 minutes). Similarly patency rates compare favorably compared to other systems such as Angiojet, Trerotola, etc. Changes in hemoglobin were not seen in 17 patients that had hemoglobin levels checked after the procedure. The biggest limitation is the small number of patients, lack of cost analysis and lack of control group for comparison. The authors conclude that the indigo system is safe and effective with promising patency rates and procedural times when compared to other systems or techniques.
Figure- Representative fistulogram demonstrates the initial injection with thrombus in the graft (A), fistulagram after antegrade thrombectomy but before angioplasty of the stenotic lesion (B), fistulagram after thrombectomy and angioplasty of the lesion (C), fistulagram from the brachial artery showing thrombus in the arterial end (D), and final fistulagram after retrograde thrombectomy.
This study provides promising data regarding the use of the Indigo system for the treatment of thrombosed dialysis access. With low procedural times, high patency rates at 6 months and low complications rates, this system has the potential to replace other systems. The authors required the use of adjunctive systems in 3 separate cases, and as expected angioplasty was required in the majority of the cases to threat the underlying lesions. The biggest limitation in this study was the lack of cost analysis and lack of control group. Future studies that compare the indigo system against other systems (mechanical thrombectomy, Angiojet, Trerotola, etc) and provides a cost analysis will elucidate if the Indigo system can become a first line system in the treatment of thrombosed dialysis access.
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Marcelin C, D'Souza S, Le Bras Y, Petitpierre F, Grenier N, van den Berg JC, Huasen B. Mechanical Thrombectomy in Acute Thrombosis of Dialysis Arteriovenous Fistulae and Grafts Using a Vacuum-Assisted Thrombectomy Catheter: A Multicenter Study. J Vasc Interv Radiol. 2018 Jul;29(7):993-997.
Carlos J. Guevara, MD
Department of Radiology, Interventional Radiology Division
University of Texas Health Sciences, Houston